Provider Demographics
NPI:1598508517
Name:KELLAM, NICOLE GUESS (OTR/L)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:GUESS
Last Name:KELLAM
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 LOWER MILL RD
Mailing Address - Street 2:
Mailing Address - City:POWHATAN
Mailing Address - State:VA
Mailing Address - Zip Code:23139-7082
Mailing Address - Country:US
Mailing Address - Phone:804-833-6454
Mailing Address - Fax:
Practice Address - Street 1:1600 WESTBROOK AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-3337
Practice Address - Country:US
Practice Address - Phone:804-256-2092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119004916225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist